Basic Information
| Provider Information | |||||||||
| NPI: | 1285662817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOBLEY | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | MILTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 E. ROUTT AVENUE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438711 | ||||||||
| FaxNumber: | 7195853038 | ||||||||
| Practice Location | |||||||||
| Address1: | 2030 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810043536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195644823 | ||||||||
| FaxNumber: | 7195644858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 01/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DEN-7119 | CO | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 44526369 | 05 | CO | MEDICAID | 0017550 | 01 | DORAL | OTHER | 200372340A | 05 | KS | MEDICAID |